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Operative Vaginal Deliveries - 2021

The document discusses operative vaginal deliveries (OVD), focusing on techniques like vacuum-assisted and forceps-assisted deliveries, their indications, contraindications, and procedural considerations. It highlights the declining use of forceps due to medico-legal concerns and preference for vacuum delivery, which accounts for over 80% of OVDs in the U.S. The document also details the proper technique for vacuum extraction and related complications for both the fetus and mother.

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Contents Introduction to Operative Deliveries Vacuum-AssistedVaginal Delivery Forceps-AssistedVaginal Delivery Sequential Use of Instruments Destructive Delivery 2
Introduction to Operative Deliveries • refers to a delivery in which the operator uses – Devices to assist mother in transitioning fetus → to Extrauterine life • Operative delivery can be divided into A. operative vaginal delivery and B. cesarean delivery • success and safety of OD depends upon – operator skill – proper timing – proper indications 3 are met while contraindications are avoided
• In Ethiopia : ➔ Ethiop.J.Health Dev.2004;18(2) – Forceps deliveries = 14.8% – Vacuum deliveries = 18.7% • UTD 2021- @  Forceps deliveries - 0.5 percent of vaginal births  Vacuum deliveries - 2.6 percent of vaginal births. • Overall rate of OVD diminishing – vacuum → increasing while forceps → declining} – 4 reasons for decline in the use of forceps >> vacuum 1. Medicolegal implications and fear of litigation 2. Reliance on CS as a remedy for abnormal labor and suspected fetal jeopardy 3. Perception that vacuum is easier to use and less risky to fetus and mother, and 4. Decreased number of residency programs that actively train residents in the use of forceps 4
ABCs of operative vaginal deliveries • A → adequate anesthesia • B → bladder must be emptied • C + D → cervix must be completely dilated • E → fetal head must be engaged • F → fontanels and direction of the occiput (position) must be precisely known • G → gush of amniotic fluid must occur (membrane must be ruptured), • H → hip size (pelvimetry) must be adequate • I → correct indication must be present • H → Halt traction when the contraction is over; halt the procedure if it is not progressing normally Recommendations OVD • classification is the same • Same indications and contraindications • Operator - should be experienced • Operator - should be willing to abandon CI for any OVD (Forceps/Vacuum)  Suspected CPD  Known fetal demineralization diseases (eg, osteogenesis imperfecta)  maternal Ehlers-Danlos syndrome  fetal bleeding diatheses (eg, thrombocytopenia or hemophilia  Suspected macrosomia - not contraindicated (ACOG) – ≥ 4000 grams: ↑ed risk of Fetomaternal injury 5
• Antibiotic prophylaxis is not necessary – no benefit has been established, although data are sparse • Factors determining choice of instrument – clinician's expertise with the various forceps and vacuum devices – availability of the instrument – level of maternal anesthesia – knowledge of the risks and benefits associated with each instrument in various clinical settings – Vacuum delivery • less traumatic for the mother than forceps delivery • easier to apply and require less maternal anesthesia than forceps – Forceps • significantly higher success rate • can be used on premature fetuses or to actively rotate the fetal head • do not aggravate bleeding from scalp lacerations 6
Vacuum delivery: compared to forceps Forceps: compared to vacuum 1. safer for mother: higher rates of fetal morbidity 2. More likely to detach from the head ➔ Higher failure rate than forceps 3. Easier to learn 4. Less maternal discomfort during & after delivery 5. should not be applied to fetuses < 34 weeks 6. biparietal diameter isn’t increased 7. easier to apply, place less force on fetal head 8. Less need for maternal anesthesia 9. Less maternal blood loss 1. safer for the fetus ➔ higher rates of maternal injury 2. unlikely to detach from the head ➔ unlikely to fail to achieve vaginal birth than vacuum 3. Greater duration of training needed 4. Greater maternal discomfort postpartum 5. Pre-term use less controversial 6. biparietal diameter is increased by the thickness of each forceps blade 7. may be used for a rotation 8. cause significantly more acute maternal injury and fetal facial nerve injury than vacuum ?????? 9. Easier to apply with caput 10. Used with breech presentation 11. Less difficult to apply to deflexed head 12. Less incidence of shoulder dystocia ❑ Failure rates : 12% ❑ Failure rate : 7% 7
8 Type Description High ▪ Not included in this classification Midforceps ▪ head is engaged (ie, at least 0 station), but the leading point of the skull is not ≥2 cm beyond the ischial spines (ie, station is 0 to +1/5 cm) Low Forceps ▪ Leading point of fetal skull is at ≥ 2 cm beyond the ischial spines and not on the pelvic floor. ▪ station is at least +2/5 cm ▪ Rotation 45 degrees or less to LOA/ROA to OA or LOP/ ROP to OP, or rotation is 45 degrees or more ▪ Low forceps have two subdivisions: o Rotation ≤ 45 degrees o Rotation > 45 degrees Outlet ▪ Scalp is visible at the introitus without separating the labia. ▪ Fetal skull has reached the pelvic floor. ▪ Sagittal suture is in the AP diameter or LOA/ROA or LOP/ROP positions. ▪ Fetal head is at or on the perineum. ▪ Rotation does not exceed 45 degrees Operative vaginal delivery classification Classification of vacuum deliveries should be the same as that used for forceps deliveries (including station)
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Vacuum-AssistedVaginal Delivery • Vacuum delivery is effected using the ventouse (vacuum extractor) • main action - traction ± rotation • Theoretical advantages of the vacuum over forceps include: – (1) avoidance of insertion of space-occupying steel blades within the vagina, – (2) no requirement for precise positioning over the fetal head, – (3) less maternal trauma, and – (4) less intracranial pressure during traction • Vacuum extraction accounts for over 80 percent of operative vaginal deliveries in the United States (UTD 2021) • three major categories of indication (NB: no absolute indication) – UTD 2021 – prolonged second stage of labor, – nonreassuring fetal status, and – shortening the second stage for maternal benefit 10
Contraindications forVacuum extraction • no quality data for firm recommendations regarding – GA & limit below which vacuum extractor should not be used • most experts limit the procedure to GA > 34 {cut-off} weeks – This is b/c premature head is likely at greater risk for compression-decompression injuries simply due to • pliability of preterm skull and • more fragile soft tissues of the scalp • Vacuum should not be applied to fetuses < 34 weeks of gestation • Experts have recommended avoiding use of vacuum devices to assist delivery before 34 weeks of gestation due to a perceived increased risk of birth injuries (Intracranial hemorrhage) in preterm infants (UTD 2021) • Relative contraindications – Prior scalp sampling or multiple attempts at fetal scalp electrode placement – because scalp trauma from these procedures theoretically may increase the risk of cephalohematoma or external bleeding from the scalp wound 11
Mnemonic for vacuum extraction 12 A o Ask for help; address the patient (inform her about what you are going to do and get informed consent); assess anesthesia needs B o Bladder empty C o Cervix fully dilated D o Determine fetal position and think shoulder dystocia E o Extractor and resuscitation equipment ready F o Apply cup on the flexion point G o Gentle traction in the proper axis H o Halt traction when the contraction is over; halt the procedure if it is not progressing normally
• Prerequisites – Vertex presentation with fetal position identified – Fully dilated cervix43 – Engaged head: station at 0 or not more than 2/5 above symphysis pupis44 – Ruptured membranes – Live fetus; Term fetus • Preparation – Empty bladder – Local anesthesia infiltration for episiotomy – Assembled and tested vacuum extractor • Indications – 1. Prolonged second stage of labor – 2. To shorten second stage in: • Maternal distress • Preeclampsia/ eclampsia • Cardiac or pulmonary diseases • Glaucoma, • Cerebrovascular disease: CNS aneurisms etc. – 3. Fetal distress and cord prolapse • Contraindications: – CPD, Fetal coagulopathy – Non-vertex presentation such face , breech (after-coming head) 13
Components ofVacuum Extractor • Main components – Vacuum force (Pump) - Electrical, hand pump or pedal pump – Suction cup • is connected to a handle grip: Metallic or Plastic • Differ in shape and size – Vacuum pump – Traction devices – Suction tube: connects cup both to a vacuum source – Traction chain – Pressure gauges 14
Decision to use ➔ soft cups Vs metal cup Cups Soft cups Metal cup Main d/ce  Easy to apply  lower incidence of scalp injury  more commonly in the United States  negative pressure can be increased to 0.8 kg/cm2 over as little as 1 minute  vacuum can be developed quickly and therefore can be released between contractions, which decreases injury to the fetal scalp due to abrasions  Fewer superficial scalp injuries  higher rates of adverse outcomes  more suitable for occiput posterior, transverse, and difficult occiput anterior deliveries  vacuum be created gradually by increasing the suction by 0.2 kg/cm2 every 2 minutes until a negative pressure of 0.8 kg/cm2 is reached  Can be autoclaved  More difficult to apply & More uncomfortable  Higher incidence of fetal scalp injuries Failure  16%  9% Detachment  22%  10% However, high-pressure vacuum generates large amounts of force regardless of the cup used 15 • Soft cups are usually bell shaped, while rigid cups tend to be mushroom shaped • Bell-shaped cups - draw chignon into the cup, thereby reducing the available vacuum area and leading to a decrease in cup adhesiveness at the edges.This allows leakage of air and eventual detachments • M-style cups - tends to draw chignon into the cup while edges interlock with the base of the chignon, thereby creating a mechanical attachment that seems to compensate for the loss of available vacuum space
Choice of vacuum cup • A soft vacuum cup is appropriate for most deliveries • Rigid cups may be preferable for – occiput posterior, – occiput transverse, and – difficult occiput anterior deliveries because they are less likely to detach 16
• 1st vacuum system – assembled & ensure that no leaks are present • Cup placement – directly over the sagittal suture at the median flexion point • to provide the smallest diameter to the maternal pelvis • Mento vertical diameter – Proper cup placement - the most important determinant of success – Anterior placement ➔ result extension – Asymmetrical placement relative to sagittal suture → worsen asynclitism • Incorrect placement on an asynclitic head results in – unequal distribution of force and – Increased risk of neonatal intracranial injury and scalp lacerations  OA: approximately 6 cm from the anterior fontanelle and 3 cm from the posterior fontanelle  OP: positioned more posteriorly and higher in the vagina 17
4 Possible positions of cup Flexing median {Ideal} Paramedian application Deflexing median Deflexing paramedian ☻cup is properly placed over the flexion point ☻cup is placed to either side of the midline, but not too far forward ☻cup is placed both too far forward but is in the midline ☻cup is placed both too far forward and off to either side ☻No problem ☻worsen asynclitism ☻result extension ☻Extension + asynclitism 18
• suction creates artificial caput succedaneum ( “chignon”) – This allows for appropriate traction force to be applied to the vertex without a “pop off” or detachment • As with forceps application ➔ the following checks : prior to traction No maternal tissue : under the cup margin • Entrapment of maternal soft tissue – Mother: lacerations and hemorrhage – Cup "pop-off" • Presence or absence of fluid trap does not affect effectiveness of vacuum Cup should be placed → @ median flexion point 19
• During contraction → along the pelvic axis – along the axis of the pelvic curve (ie, down then up) • Intermittent : If > 1 contraction is necessary – vacuum pressure can be decreased to low levels between contractions • descent of fetal head should occur with each pull, ➔ 3Ds 1st pull → flexion of head & descent → Dislodge 2nd pull → head should be on pelvic floor → Descent 3rd pull → Deliver • Maximum – number of cup detachments : limited to two or three – duration of vacuum application prior to abandonment of the procedure: 20 to 30 minutes • If No progress or ≥ 2 "pop-offs" ➔ CPD should be suspected → cesarean delivery 20
• Recommended pressures: – Vacuum suction pressures of 500 to 600 mmHg have been recommended, although pressures in excess of 450 mmHg are rarely necessary • NB: 0.8 kg/cm2 of atmospheric pressure = 600 mmHg = 23.6 inches of Hg = 11.6 lb/in2 (pounds per square inch) – Create a vacuum of 0.2 kg/cm2 (approximately 200 mmHg) negative pressure and check that maternal tissue (cervix or vagina) is not entrapped – Gradually increase the vacuum to 0.8 kg/cm2 (approximately 600 mmHg), and recheck the application and that maternal tissue is not entrapped – Induce a vacuum pressure of 20 kpa (0.2 kg/cm2) and recheck the cup position. – Then increase the vacuum in one step to the recommended pressure of 80 kpa (0.8 kg/cm2) • Delay traction for 2 minutes to allow chignon to form – 0.2 kg / 2 min = rigid cap – 0.8 kg / 1 min = soft cap – Slow, stepwise application of suction does not improve safety or efficacy ContinualVersus Intermittent Vacuum Pressure • Pressure can be maintained or released between contractions with no change in outcome • Traction should be discontinued between contractions 21
• Detachment of the suction cup from fetal head • Associated with increased fetal head trauma • Caused by:  Maternal tissue or scalp electrode caught under edge of cup  Incorrect technique (pulling too hard, in wrong direction, or without a contraction)  Large caput succedaneum  Deflexing or paramedian application  Bending or twisting the cup, handle, or shaft  Rotating the cup  Inadequate pressure or faulty equipment • So re-evaluate the site of application, direction of axis traction, and fetal maternal pelvic dimensions. Duration • The maximum time to safely complete a vacuum assisted delivery and the number of acceptable "pop-offs" are unknown • Ff are commonly recommended.. a maximum of – two to three cup detachments – three sets of pulls for the descent phase – three sets of pulls for the outlet extraction phase, and/or – a maximum total vacuum application time of 15 to 30 minutes 22
FailedVacuum • Diagnosis is based on any one of the following conditions – The head does not advance with each pull; – The fetus is not delivered with 3 pulls; – The fetus is not delivered within 30 minutes; – The cup that is applied appropriately and pulled in the proper direction with maximum negative pressures slips off the head twice • After failed vacuum, the fetus is delivered by Cesarean section. Every vacuum application should be considered as a trial of vacuum delivery • Some reasons for failure include: – Fetopelvic disproportion – Incorrect technique – Paramedian or deflexing applications – Large caput succedaneum 23
Complications • Fetal – Localized scalp oedema (caput succedaneum or chignon) under the vacuum cup is harmless and disappears in few hours. – Laceration of scalp: provide local wound care as appropriate; – Cephalhematoma requires observation: usually clears within 3-4 weeks – Subaponeurotic hemorrhage – Intracranial hemorrhage: very rare but requires immediate intensive care – Necrosis is extremely rare. • Maternal – Tears of the vagina or cervix are repaired as appropriate 24
• With vacuum extraction, a metal cup compared with a soft cup is associated with significantly higher rates of which of the following? – A. Cephalohematoma B. Birth canal trauma – C. Low Apgar scores D. None of the above • In general, vacuum extraction would be contraindicated in all EXCEPT which of the following clinical settings? – A. 30-week fetus – B. Fetal thrombocytopenia – C. Occiput transverse presentation – D. Inability to assess fetal head position • With vacuum extraction, correct cup placement is described by which of the following? – A. Centered across the sagittal suture – B. Placed over the posterior fontanel – C. If ROA, the cup is placed on left fetal parietal bone. – D. Traction axis is aligned with the suboccipitobregmatic diameter 25
Forceps-AssistedVaginal Delivery 26 A Triple Obstetric Tragedy • Death of mother, her son & the midwife • November 6, 1817 – Princess Charlotte’s labor • managed by Sir Richard Croft • SSOL = lasted 24 hour, including 6 hours on the perineum • Then ➔ Princess delivered a 9 lb (4 kg) stillborn male heir – within 24 hours of delivery, the Princess herself died of a massive postpartum hemorrhage – Disturbed with depression and despair at the blame for the death of both the Princess and the heir to the British throne, Croft shot himself 3 months later – Forceps was not applied for fear of infection (there was no antiseptics) • This triple tragedy allows more liberal use of forceps & earlier intervention
• Indications – Prolonged second stage – To shorten the second stage in cases with • Maternal distress • Preeclampsia, eclampsia • Cardiac or pulmonary diseases • Glaucoma, • Cerebrovascular diseases: aneurysm, CVA etc – Fetal distress and cord prolapse – After-coming head in breach presentation • Prerequisites – Presentation & position Vertex presentation with occipitoanterior or occiput posterior Face presentation with mentoanterior After-coming head in breech (Piper’s forceps) Engaged head with a station of +2 or below Fully dilated cervix Ruptured membranes No contraindication to vaginal delivery such as CPD • The two acceptable forceps operations with minimum trauma to the mother and fetus are: – Low forceps: application when the leading part of the fetal scalp is at station +2 or below but not on the pelvic floor. – Outlet forceps: application when the head is at perineum and visible at introitus between contractions.The fetal scalp has reached the pelvic floor 27
Anatomy of Forceps • two crossing branches • Each - four components: ❑ Handle → Lock → Shank → Blade • has two curves 1. Cephalic curve • conforms to the shape of fetal head & even distribution of force 2. Pelvic curve • Ease of application - pelvic axis • Heel: the back of the blade • May be – solid (Tucker-McLane) – Fenestrated (Simpson) or – pseudo fenestrated (Luikart-Simpson) 28  Handles transmit the applied force  Lock : fulcrum  Blades transmit the load
Pelvic & cephalic curve, shank, blade, lock, and handle • are different for each type of forceps • These features determine the type of forceps - best suited for appropriate indication – Simpson or Elliot forceps • most often used for vaginal deliveries • Simpson forceps are suited for application to fetal head – Molded head: common in nulliparous women – Kielland or Tucker-McLane forceps • used for rotational deliveries • Kielland forceps – better ??? {see above} – Tucker-McLane forceps have • shorter, solid blade and • overlapping shanks » more often used for rotations than other classic instruments. – Piper forceps • for delivery of the aftercoming head : breech deliveries • b/c → have a reverse pelvic curve compared to other forceps ❑ NB: Elliott or Tucker-McLane type forceps are better suited to a round unmolded head ➔ Because these instruments have a more rounded cephalic curve – rounded head: more characteristically seen in multiparas 29
Forceps Classification - according to their intended use 1. Classic 2. Rotational 3. Specialized Purpose:Traction Kielland {frequently used },Tucker-McLane Piper forceps English lock sliding lock English lock Typically used when rotation of vertex is not required for delivery →However, they may be used for rotations such as the Scanzoni- Smellie maneuver { rotation from OP to OA} type is determined by its shank 1. parallel: Simpson, DeLee, Irving, and Hawks Dennen 2. overlapping: Elliott and Tucker- McLane cephalic curve - amenable to application to molded vertex pelvic curve: Reverse {either only a slight curve or none at all overlapping shanks Why Kielland – best for rotation ??? 1. straight design : places handle & shanks in the same plane as the long axis of the fetal head ➔ allow toe to travel through a very small arch during rotation 2. Long distance between the heel and intersecting point of shanks ➔ accommodates heads of various shapes and sizes associated with unusual molding. 3. Reverse pelvic curve ➔ facilitates rotation of vertex without moving handles through a wide arch 4. Sliding lock: permits placement of the handles at any level on the shank to accommodate the asynclitic head and subsequent correction of asynclitism aftercoming head {Assisted BVD} reverse pelvic curve long parallel shanks : permit body of the breech to rest against it during delivery of head 30
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Novel devices Thierry orTeissier spatula • consist of two independent and symmetric branches which include a shank, handle, and wide solid blade • The shanks do not articulate; thus, each branch acts as an independent lever and the head is not compressed between the blades • Outcome data are limited and primarily published in French, but neonatal complication rates appear to be similar to, or slightly lower than, rates with other instruments • In one large study, the rate of severe perineal injuries was equivalent to that reported with other extraction instruments, but vaginal tears were more common 32
Odon device • developed by the World Health Organization for use in areas that have limited or no access to cesarean birth • It is a low-cost device made of film-like polyethylene material that creates a sac filled with air that surrounds the entire head and enables extraction when traction is applied • It has the potential to be safer and easier to apply than forceps or a vacuum extractor • No randomized trials have published data regarding its safety and efficacy. • In a pilot observational study, the Odon Device alone assisted in the birth of 19 of the 40 newborns, with no serious maternal or neonatal adverse outcomes related to its use 33
• Before the application of forceps, determine – Position, station – adequacy of pelvic diameters of midpelvis and outlet • 1st left Blade ➔ Right blade – When blades are inserted in this order: right shank comes to lie atop the left • If there is any resistance to blade entry into maternal pelvis – blade should be removed and – application technique re-evaluated • 3 – Applications – Bimalar-Biparietal: Optimal – Fronto- Mastoid: Suboptimal – Fronto-Occipital: • blades should have a bimalar, biparietal placement when applied properly • After positioning, the branches are articulated 34
• three landmarks in checking a proper forceps application: 1. Posterior fontanelle: should be • one finger breath above the plane of shanks • equidistant from the sides of the blades: midway between the blades • directly in front of the articulated forceps 2. Sagittal suture • perpendicular to the plane of the shanks • blades - equidistant from sagittal suture 3. Fenestration : If fenestrated (open) blades are used • should be barely palpable • the amount of fenestration in front of the fetal head should admit no more than the tip of 1 finger • Appropriately applied forceps grasp : OA fetal head such that : ☻long axis of blades corresponds to occipitomental diameter ☻tips of blades lie over the cheeks ☻No maternal tissue has been grasped. ❑ Once the forceps articulate, the above checks should be performed before any traction 35
• Pelvic shape → • DirectionVs traction – Initially :Horizontal – vertically as fetal head extends {crowns } ► b/c head negotiates the final position of pelvic curve by extension • Traction should be steady (not rocking) • applied during contractions • should be intermittent – head should be allowed to recede in intervals, as in spontaneous labor • Except when urgently indicated, as in severe fetal bradycardia, – delivery should be sufficiently to prevent undue head compression • Amount of traction force – Primiparas: 20 kg – Multiparas: 13 kg – no consensus • Traction axis principle – force is directed in two vectors – Downward and Out • One hand holds the shanks and exerts downward traction while • operator's other hand holds the handles and exerts traction outward • Episiotomy – as vulva is distended by the occiput • Disarticulation: – as the head crowns in the reverse order of application • first right blade ➔ left blade – To reduce the risk of laceration • before widest diameter of fetal head passes through the introitus – Modified Ritgen maneuver • Upward pressure from coccygeal region to extend the head during actual delivery, thereby protecting the musculature of the perineum 36
37 Method of axis traction • Pajot-Saxtorph maneuver: left hand grips the shanks and exerts a downward pull.The right hand grips the handles and exerts a pull parallel to the floor
Choice of forceps • Size and shape of fetal head and maternal pelvis - should match the size, cephalic curve, and pelvic curve of the forceps – Simpson type forceps - best fit for a molded head because of the less concave cephalic curve. – Elliott type forceps orTucker-McLane type forceps - better suited to a round, unmolded head as the cephalic curve of the forceps is more concave. – Fenestrated blades allow for a better grip and therefore are less likely to slip, but the fenestrations increase the risk for tissue laceration when greater forces are applied • Solid blades are less likely to lacerate the fetal head but may be more likely to slip with increased traction • Pseudo fenestrated blades have a shallow indentation rather than a true fenestrated, which may reduce slippage while also reducing risks of laceration. • Direction of traction and type of rotation – Kielland forceps - useful for rotations because of their minimal pelvic curve and sliding lock • A sliding lock is helpful when there is asynclitism. – Piper forceps are used to deliver the aftercoming head in vaginal breech deliveries • Station – Midpelvic deliveries - Bill's axis traction handle or Irving forceps • Operator experience and preference 38
• Introduced by Dee Lee (1920) • refers to outlet forceps delivery, only to – shorten the second stage of labour for prevention of anticipated maternal or fetal complications in • Eclampsia, Heart disease, Previous CS • Post maturity, During epidural anaesthesia • Low birth wt babies – no significant differences in outcomes in neonates who weighed 500 to 1500 g and who were delivered spontaneously or by outlet forceps • no consensus impact of prophylactic low forceps delivery {in low birth weight infants} – Some ➔ increased risk of intraventricular hemorrhage with prophylactic low forceps – Others ➔ no differences in neonatal outcome between infants delivered by low forceps and spontaneously – maternal body mass index > 30 – estimated fetal weight > 4000 g or clinically big baby – occipito-posterior position – mid-cavity delivery or when 1/5 head palpable per abdomen 39
Failed Forceps • A failed forceps is diagnosed if: – Fetal head does not descend with each pull, – Fetus is undelivered after three pulls with no descent or after 30 minutes • The possible causes are: – Undiagnosed CPD – Incomplete cervical dilatation – Wrong diagnosis of position – Incorrect application – Cervical entrapment • When application of forceps or traction does not yield, reassess for possible cause.After a failed forceps, Cesarean delivery is undertaken if the fetus is alive • If an attempt at operative vaginal delivery is anticipated to be difficult, the attempt should be considered a trial 40
Maternal Vs Neonatal Risks • Maternal and fetal complication rates depend on ff factors  Parity  Forceps: type  Vacuum: cup position & type  position & station at application  Posterior presentation  Increased birth weight  Rotation of > 450 1. Asphyxia 2. Trauma – Intracranial haemorrhage – Cephalic haematoma – Facial / Brachial palsy – Injury to the soft tissues of face & forehead – Skull fracture 3. Remote-cerebral palsy. – Fetal death - around 2% ??? 1. Injury – Extension of the episiotomy involving anus & rectum or vaginal vault. – Vaginal lacerations and cervical tear if cervix was not fully dilated. 2. PPH trauma,Atonic uterus or Anaesthetisia 3. Shock  blood loss, dehydration or prolonged labour 4. Sepsis – Due to improper asepsis or devitalisation of local tissues 5. Anaesthetic hazards. 6. Delayed or long-term sequel – Chronic low backache, genital prolapse & stress incontinence. 41
• A 41-year-old G1P0 at 39 weeks, who has been completely dilated and pushing for 3 h, has an epidural in place and remains undelivered. She is exhausted and crying and tells you that she can no longer push. Her temperature is 101°F.The fetal heart rate is in the 190s with decreased variability. The patient’s membranes have been ruptured for over 24 h, and she has been receiving intravenous ampicillin for a history of colonization with group B strep bacteria.The patient’s cervix is completely dilated and effaced and the fetal head is in the direct OA position and is visible at the introitus between pushes. Extensive caput is noted, but the fetal bones are at the +3 station. – What is the most appropriate next step in the management of this patient? • a. Deliver the patient by CS b. Encourage the patient to continue to push after a short rest • c.Attempt operative delivery with forceps d. Rebolus the patient’s epidural • e. Cut a fourth-degree episiotomy – Compared to the use of the vacuum extractor, forceps are associated with an increased risk of which of the following neonatal complications? • a. Cephalohematoma b. Retinal hemorrhage c. Jaundice • d. Intracranial hemorrhage e. Corneal abrasions – What kind of forceps would be most appropriate to use in this delivery? • a. Kielland b. Piper c. Simpson – During the delivery, it is necessary to cut an episiotomy.The tear extends through the sphincter of the rectum, but the rectal mucosa is intact. How would you classify this type of episiotomy? • a. First-degree b. Second-degree c.Third-degree d. Fourth-degree 42
• In current obstetrics, forceps deliveries are categorized into one of the following three groups? – Midforceps, low forceps, outlet forceps • Describe a forceps applied to the fetal head at +1 station? – Midforceps • Advantages to elective forceps delivery include which of the following? – A. Lower rates of fetal acidosis – B. Prevention of perineal laceration – C. Lower rates of postpartum urinary retention – D. None of the above • High forceps delivery – has No role in modern obstetrics 43
• During forceps delivery of a fetus with a face presentation, blades should be swept upward when which of the following passes beneath the symphysis? – A. Chin B. Brow – C. Upper lip D. Base of the nose • During operative delivery of a fetus from a +2 station and ROA position, movements of the forceps should follow which sequence? – Rotation, outward traction, upward traction • Fetal indications for forceps delivery include which of the following? – A. Fetal coagulopathy – B. Fetal congenital heart block – C. Nonreassuring fetal heart rate pattern – D. Protection of fragile preterm infant head • Factors associated with a failed trial of forceps and need for cesarean delivery include which of the following? – A. Advanced parity – B. Coexistent chorioamnionitis – C. Poor maternal pushing efforts – D. Absence of regional or general anesthesia • For the fetus, forceps delivery, compared with spontaneous vaginal delivery, is associated with higher rates of all EXCEPT which of the following complications? – A. Facial palsy – B. Impaired intelligence – C. Brachial plexus injury – D. Intracranial hemorrhage • When correctly applied to a fetus in an occiput anterior position, forceps align along which fetal head diameter? – A. Bitemporal B. Occipitofrontal – C. Occipitomental – D. Suboccipitobregmatic • When correctly applied to a fetus with a face presentation, forceps align along which fetal head diameter? Occipitomental 44
Sequential Use of Instruments • should not be performed routinely • For a procedure to be considered sequential, traction is applied sequentially by two different instruments – Situations in which an instrument is placed, but no traction applied, should not be considered a sequential attempt – for instance, when proper placement of forceps cannot be achieved, or a vacuum device fails to achieve suction and no traction has been applied • sequential use of vacuum extraction and forceps – increases the likelihood of adverse maternal and neonatal outcomes • more than the sum of the relative risks of each instrument • ACOG {2000} : cautions that these • trials are attempted only if the clinical assessment is highly suggestive of a successful outcome – balance the risks of a caesarean section with the risks of sequential use of Instruments – Caesarean section in the second stage of labor is associated with an increased risk of • major obstetric hemorrhage • prolonged hospital stay and 45
Destructive Delivery • Reductive surgical procedure performed on the dead fetus to reduce its size and make vaginal delivery possible • Main advantages: – Need few instruments – prevention of  Cesarean delivery: Leaves the mother with intact uterus  Dissemination of infection associated with obstructed labor • If she is already infected, low risk of spread of infection to the peritoneum  Maternal trauma • Craniotomy • Craniocentesis • Evisceration • Decapitation • Cleidotomy 46
Indications of DVD • CPD, Breach delivery • Transverse lie Prerequisites for DVD • Dead fetus • Fully dilated cervix • No gross pelvic contracture • No risk of uterine rupture • 2/5 or less of his head must be above the brim • Back up operative facilities Preparations of pts for DVD • hydrate - crystalloid • Hb, B/G & Rh {??}, cross matched blood • Broad spectrum antibiotics • Catheterize • Consent of patient/ parent • Aseptic & antiseptic care • Anesthesia as per individual need • Alert the OR staff • Lithotomy position 47
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49 Budin’s cannula
Craniotomy • head - perforated to evacuate the brain tissue Indication • Obstructed labor with a vertex or face • Arrested after coming head • Interlocked head of twins • Contracted pelvis is the most common indication Contraindication • Severely contracted pelvis with – true conjugate < 7.5 cm – won’t allow the delivery of the uncompressible bimastoid which has 7.5 cm diameter • Ruptured uterus (Laparotomy needed) • Dead fetus without obstruction ???? • Doubtful fetal demise – Benefit of doubt goes to mother & fetus • Ruptured membranes • Instruments: – Oldham’s perforator – Budin’s cannula – Big Mayo’s scissor 50 Presentation & Site of Entry Presentation Site of Entry: perforator or scissors Vertex ☻Parietal bones either side of sagittal Suture Face ☻Orbit/hard palate Brow ☻Frontal bones After coming head ☻Foramen magnum
ScalpTraction • Introduce the perforator, with closed blade, under palmar aspect of fingers protecting anterior vaginal wall and bladder at predetermined site.Avoid sudden sliding of your instrument over the skull and getting into maternal tissue. • Open the perforator or the scissors and rotate it to disrupt the brain tissue; the brain tissue should now be coming out from the hole. • Put 3-4 strong vulsellum forceps, kochers or heavy-toothed forceps on the skin and bones and pull on the forceps to achieve vaginal delivery. • Protect the vagina by avoiding sharp scalp bone edges tearing the vaginal wall by your finger or by removing the offending bones. • As the head descends, pressure from the bony pelvis will cause the skull to collapse, decreasing the cranial diameter 51
Craniocentesis • to deliver the hydrocephalic head through – Vaginal or Uterine incision at time of cesarean section INDICATION • Cephalic or after coming breech presentation with hydrocephalic dead fetus • A Live fetus with congenital malformation incompatible with life and severe hydrocephalus (HC>40cm) 52 Cephalic presentation with After-coming head Dilated cervix Closed cervix  large-bore spinal needle →  Sagittal suture line or fontanel  Palpate - location of fetal head  Needle through the abdomen and uterine wall {suprapubic area} → hydrocephalus head ➔ Drain CSF  Two ways of CSF draining: needle → 1. Foramen magnum 2. Spinal canal (spondylectomy)  If fetus has spina bifida ❑Drain by reaching cranium through the defect and spinal cord  Drain CSF until skull has collapsed and allow normal delivery to proceed • Pass a large-bore spinal needle through the dilated cervix and through the sagittal suture line or fontanel of the fetal skull • Drain / aspirate the CSF until the skull has collapsed and allow normal delivery to proceed.
Evisceration • is removal of thoracic and or abdominal contents through an opening at most accessible site on the abdomen or thorax • Indications – Neglected shoulder presentation with dead fetus & neck not accessible for decapitation – Fetal malformation (fetal ascites, monsters, distended bladder & hydronephrosis) • Instruments: Embryotomy Scissor 53
Decapitation • is severing the fetal head ➔ – Trunk and decapitated head → delivered separately • Indication – obstructed labor in shoulder presentation when the neck is easily accessible – locked twins • Instruments – Decapitation hook with Jardin’s knife – Embryotomy scissor – Hook with crochet : to pull – GiantVulsellum • in transverse lie – neck of the fetus has to be accessible for decapitation: If the neck • can be reached ➔ attempt decapitation • is difficult to reach but the body is well down➔ attempt evisceration • & body are both still high in the birth canal ➔ cesarean section 54
Cleidotomy • Cleidotomy is used to reduce the bulk of the shoulder girdle of the dead fetus by cutting one or both clavicle(s) • It is indicated in shoulder dystocia 55
Post-destructive operation care • Explore the uterus, cervix and vagina and treat accordingly • Repair episiotomy • catheter for 7-14 days • Treat infection: Broad spectrum antibiotics – Cover G-ves + Anaerobes • Correct anemia , dehydration and hypovolemia • Suppress possible breast engorgement • Help the woman morn loss of her fetus and counsel her on future pregnancy Complications of destructive operations:- • Post partum hemorrhage due to atonic uterus or genital trauma • Shock due to hemorrhage or sepsis • Trauma to birth canal • Puerperal sepsis • Injury to adjacent organs -VVF,UVF or RVF 56